International Journal of Anesthesia and Clinical Medicine

2023; 11(1): 5-13

http://www.sciencepublishinggroup.com/j/ijacm
doi: 10.11648/j.ijacm.20231101.12
ISSN: 2376-7766 (Print); ISSN: 2376-7774 (Online)

Anesthesiological Management of Acute Generalized

Peritonitis at Chu Kara
Essohanam Tabana Mouzou1, *, Sarakawabalo Assenouwe1, Pikabalo Tchetike2,
Eyram Yoan Makafui Amekoudi1
1
Faculty of Health Sciences (FSS), University of Kara, Kara, Togo
2
Faculty of Health Sciences, University of Lomé, Lomé, Togo

Email address:

*
Corresponding author

To cite this article:

Essohanam Tabana Mouzou, Sarakawabalo Assenouwe, Pikabalo Tchetike, Eyram Yoan Makafui Amekoudi. Anesthesiological
Management of Acute Generalized Peritonitis at Chu Kara. International Journal of Anesthesia and Clinical Medicine.
Vol. 11, No. 1, 2023, pp. 5-13. doi: 10.11648/j.ijacm.20231101.12

Received: December 24, 2022; Accepted: January 11, 2023; Published: January 31, 2023

Abstract: The aim of our work was to make an inventory of the anesthesiological management of acute generalized
peritonitis at the CHU-Kara. To determine the frequency of acute generalized peritonitis; to describe their treatment in pre, per
and postoperative; to analyze the postoperative follow-up. This work was a retrospective descriptive study carried out on the
files of patients operated for acute generalized peritonitis from November 1, 2019 to October 31, 2020. The study was
performed in the surgical resuscitation department and in the operating room. Fifty-eight cases of generalized peritonitis were
selected for the study. Peritonitis represented 27.8% of abdominal surgical emergencies. The patients were male dominated
with a mean age of 29.6 years. The average consultation time was 3.5 days. Fever was the predominant clinical sign on
admission (72.4%). The average duration of preoperative resuscitation was 17 hours and 18 minutes. The combination of
Ceftriaxone and Metronidazole was the most used antibiotic therapy. General anesthesia was standard. Spinal anaesthesia was
the second technique used. Preoxygenation was systematic for general anesthesia. Pancuronium (72.2%) was the most used
curare. The average duration of anesthesia was 105 minutes. Laparotomy, peritoneal cleansing and drainage were performed in
all patients, followed by excision-suture of the stomach (43.1%). Peritonitis due to peptic ulcer perforation predominated
(43.1%) followed by typhoid perforation of the small intestine (24.1%). The morbidity rate was 41.4%, dominated by parietal
suppurations (15.5%). The mortality rate was 8.6%. The average length of stay in intensive care was 8.7 days. The
anesthesiological management of acute peritonitis remains a real challenge for anesthesiologists, given the major volume
disturbances, the delay in diagnosis with its corollary of septic shock, and the lack of qualified personnel with which they are
faced. Peritonitis is a real public health problem because of its still very high mortality. It was carried out with insufficiencies
related to the poverty of the population, the inexistence of universal health insurance, the insufficiency of the technical
platform and the insufficiency of organization.
Keywords: Anesthesiology, Acute Generalized Peritonitis, Treatment, CHU-Kara, Togo

morbidity and mortality [1].

1. Introduction
Peritonitis is an acute inflammation or infection of the
peritoneal serosa, most often secondary to the perforation of
a digestive organ and/or the spread of an intra-abdominal
septic focus [1].
It remains a public health problem in Africa in terms of
It is the third most common emergency in digestive
surgery in Africa after occlusions and acute appendicitis [2].
The management of this pathology combines standard
resuscitation measures with systematic emergency surgical
eradication of intraperitoneal infectious foci [1].
In Europe and the USA, progress has been made in the
6 Essohanam Tabana Mouzou et al.: Anesthesiological Management of Acute Generalized Peritonitis at Chu Kara
anesthetic management of increasingly fragile patients with
more severe lesions, with a significant reduction in deaths,
thanks to measures and recommendations from learned
health societies [3].
In Africa, where the countries have in common the scarcity
of qualified anaesthetists, the shortage of structures, adapted
drugs and materials and the insufficiency of equipment
maintenance [2, 4], the management of acute peritonitis is
still marked by a high morbidity and mortality.
In Togo, until now, there has been no study on the
anesthesiological management of acute generalized
peritonitis. This motivated this work whose aim was to assess
the anesthesiological management of acute generalized
peritonitis at the University Hospital of Kara by determining
the frequency, describing the management and analyzing the
operative follow-up.
2. Materials and Methods
2.1. Location of the Study
The study took place in the surgical resuscitation
department of the Centre Hospitalier Universitaire de Kara
(CHU-Kara), a national reference center in the northern part
of Togo with more than one third of the population.
2.1.1. Surgical Resuscitation Service: Infrastructure,
Equipment and Organization
The resuscitation department located east of the operating
room, had 8 beds, equipped with two multiparametric
monitors, one of which was functional, a respirator, a
functional defibrillator. It employed one anesthesiologist,
three paramedics in anesthesia and resuscitation, including
one supervisor of the service, four (4) nurses, four (4) patient
guards.
Four teams composed of a nurse, a paramedical in
intensive care anaesthesia and a patient guard ensured all the
care per day including weekends and holidays every 12 hours.
2.1.2. Operating Room: Infrastructure, Equipment and
Organization
It had 3 operating rooms with anesthesia equipment; it
employed four anesthesia paramedics, including an operating
room supervisor and 6 patient guards, 4 instrument
technicians and about ten surgeons for scheduled activities
and emergencies. Organizationally, three paramedical
anesthetists worked every 72 hours and the OR supervisor
every working day.
2.2. Study Method
This was a retrospective descriptive and analytical study
carried out on the records of patients managed for acute
generalized peritonitis. Data collection was carried out from
February 23 to March 8, 2021 (two weeks).
2.2.1. Sample
It concerned the records of patients treated for generalized
acute peritonitis at CHU-Kara from November 1, 2019 to
October 31, 2020.
(i). Inclusion Criteria
Were included the records of patients of any age and both
sexes operated on for acute generalized peritonitis from
November 1, 2019 to October 31, 2020.
(ii). Non-Inclusion Criteria
All patients with localized peritonitis or acute generalized
peritonitis not operated on (patients who discharged due to
lack of financial means or death before surgical management)
were not included in the study. Records of patients operated
for acute generalized peritonitis without an anesthesia record
were not included.
2.2.2. Data Collection
(i). Collection Method
The supervisors of the intensive care and general surgery
units made patient records available to us.
We observed and described the structures of the surgical
resuscitation and the operating room after authorization from
the supervisors of two services.
We selected the anesthesia records, the anesthesia charts,
the ICU and OR registers of patients operated on for
generalized peritonitis with the help of the supervisors and
student trainees.
(ii). Means Used
The means used for the collection of data were: the
registers of the surgical resuscitation and the operating room,
the files of patients from the surgical resuscitation and
general surgery, the treatment and monitoring sheets and an
individual survey sheet used as a support.
(iii). Studied Parameters
The parameters studied were the following:
Socio-demographic aspects, surgical and anesthesiological
aspects, postoperative care and postoperative follow-up.
2.2.3. Data Processing and Analysis
The data collected were entered into a database using EPI
Data software version 3.1. The statistical analysis was done
with Microsoft office Excel version 2013.
2.2.4. Ethical Considerations
An official authorization note was obtained from the
management of the CHU-KARA allowing access to medical
records. The anonymity of the medical records was
respected.
3. Results
3.1. Socio-Demographic Data
3.1.1. Frequency of Acute Generalized Peritonitis
During the study period, 209 surgical abdominal
emergencies were recorded, including 58 generalized
peritonitis (27.8%).
 International Journal of Anesthesia and Clinical Medicine 2023; 11(1): 5-13 7

3.1.2. Age of the Patients 3.2.3. Etiological Aspects

The average age was 29.6 years with extremes of 6 and 67
years. Table 3. Distribution of patients according to the etiology of the peritonitis.

Number Percentage
3.1.3. Sex of the Patients Gastric ulcer perforation 25 43.1
Thirty-seven (37) patients (63.8%) were men and 21 Typhoid perforation 14 24.1
patients (36.2) were women with a sex ratio of 1.8. Appendicular 10 17.2
Genital 7 12.1
3.1.4. Main Activities of Patients Diverticular 2 3.4
Farmer 13 cases (22.4%); Schoolboy 10 cases (17.2%); Total 58 100
Farmer 7 cases (12.1%); Housewife 7 cases (12.1%);
3.3. Preoperative Resuscitation
Shopkeeper 6 cases (10.3%); Civil servant 4 cases (6.9%);
Worker 3 cases (5.2%); Other individuals 8 cases (13.8%). 3.3.1. Fluid and Energy Intake
ISS 0.9% 58 cases (100%); LR 35 cases (60.3%); SGH 10%
3.1.5. Origin of the Patients
27 cases (46.6%); SGI 5% 10 cases (17.2%).
Rural area 35 (60.3%); urban area 21 (36.2%); other
country 2 (3.5%). 3.3.2. Oxygenation
The percentage of patients oxygenated preoperatively was 19%.
3.1.6. Hour to Admission
The average admission time was 84 hours (3.5 days) with 3.3.3. Transfusion
extremes of 9 hours and 6 days. Two (3.4%) patients received a transfusion of two bags of
packed red blood cells each.
3.1.7. Mode of Admission
Referred 39 cases (67.2%); received in consultation 17 3.3.4. Probabilistic Antibiotic Therapy
cases (29.3%); referred 2 cases (3.5%). 51 patients (87.9%) received Ceftriaxone + Metronidazole;
4 patients (6.9%) Ceftriaxone + Metronidazole +gentamycin;
3.1.8. Treatment Received Before Admission
3 patients (5.2%) Ciprofloxacin + Metronidazole.
Analgesics 24 cases (41.4%); antimalarials 18 cases (31%);
antibiotics 13 cases (22.4%); 13 cases ignored; 8 cases with 3.3.5. Duration of Preoperative Resuscitation
herbal infusion (13.8%). The average duration of preoperative resuscitation was 17
hours and 18 minutes with extremes of 4 and 50 hours.
3.2. Diagnostic Aspects
3.4. Perioperative Period
3.2.1. Clinical Signs
3.4.1. Type of Anesthesia
Table 1. Distribution of patients according to clinical examination signs on
admission. General anesthesia plus orotracheal intubation was
performed in 54 (93.1%) patients. Four (6.9%) patients had
Number Percentage received spinal anesthesia.
Hyperthermia 42 72.4
Tachycardia 34 58.6 (i). Preoxygenation
Polypnea 26 44.8 Preoxygenation was systematic. It was performed in all
Oliguria 18 31 patients (100%).
Pale conjunctiva 16 27.6
Altered consciousness 10 17.2 (ii). Premedication
Hypotension 4 6.9 Atropine + Diazepam + Fentanyl 21 (36.2%); Atropine +
Fentanyl 19 (32.8%); Atropine + Diazepam 11 (19.0%);
3.2.2. Paraclinical Examinations Atropine 5 (8.6%); Fentanyl 2 (3.4%).
Table 2. Distribution of patients according to paraclinical examinations (iii). General Anesthesia Induction Protocol
performed. Pancuronium 39 cases (67.2%); Propofol 31 cases (53.4%);
Number Percentage Fentanyl 30 cases (51.7%); Ketamine 23 cases (39.7%);
Rhesus grouping 58 100 Forene 10 cases (17.2%); Rocuronium 5 cases (8.6%).
Uremia + Blood glucose + Creatinine 58 100
(iv). General Anesthesia Maintenance Protocol
CBC* 58 100
ASP** 54 91.4
Fentanyl 39 cases (67.2%); Propofol 32 cases (55.2%);
Abdominal ultrasound 16 27.6 Forene 10 cases (17.2%); Ketamine 7 cases (12.1%);
Blood ionogram 6 10.3 Rocuronium 2 cases (3.4%).
Hemostasis workup 4 6.9
3.4.2. Protocol of Locoregional Anesthesia
CT was not performed*: Blood cell count; **: X-ray of the abdomen without (Rachianesthesia)
preparation. Bupivacaine was administered in two (3.4%) patients and
8 Essohanam Tabana Mouzou et al.: Anesthesiological Management of Acute Generalized Peritonitis at Chu Kara

the combination of Bupivacaine and Morphine in two other 3.6. Evolution

(3.4%) patients.
3.4.3. Duration of Anesthesia
The average duration of anesthesia was 1 hour 45 minutes
with extremes of 1 hour and 3 hours 45 minutes.
3.4.4. Intraoperative Complications
There were no intraoperative complications.
3.4.5. Surgical Treatment
Table 4. Distribution of patients by surgical treatment.
Number
Excision + suture of the stomach 25
Excision + suture of the small intestine 11
Appendectomy + lavage + drainage 10
Laparotomy + washing + drainage 6 10.3
Resection + ileal anastomosis 3 5.2
Resection + colonic anastomosis 2 3.5
Hysterectomy 1 1.7
Total 58
3.5. Postoperative Care
3.5.1. Hydroelectrolyte and Energy Intake
SSI 0.9% 58 cases (100%); Nacl + Kcl 58 cases (100%);
SGH 10% 54 (93.1%); RL 10 cases (17.2%).
3.5.2. Antibiotic Therapy
Ceftriaxone+Metronidazole 38 cases (65.5%);
Ceftriaxone+Metronidazole+Gentamycin 11 cases (19%);
Ceftriaxone+Métronidazole+Ciprofloxacine 6 cases (10.3%);
Metronidazole+ Ciprofloxacin 3 cas (5.2%).
3.5.3. Treatment of Postoperative Pain
Paracetamol + Nefopam 39 cases (67.2%); Paracetamol +
NSAIDs 9 cases (15.5%) Paracetamol + Nefopam +
Morphine 4 cases (6.9%); Paracetamol + Tramadol 3 cases
(5.2%).
3.5.4. Antiulcer Treatment
For the prevention of stress ulcers, antiulcer drugs were
administered to 27 (46.6%). The most commonly used drug
was a proton pump inhibitor (Omeprazole).
3.5.5. Anticoagulant Treatment
Two (2) patients received anticoagulation.
3.5.6. Monitoring
Clinical monitoring included temperature, blood pressure,
heart rate, respiratory rate, oxygen saturation, diuresis,
nasogastric tube, drain, and the state of the surgical wound,
the resumption of transit, the lungs and the heart. This
monitoring was performed postoperatively in all patients
(100%).
Paraclinical monitoring: this was based on clinical signs. A
CBC was performed in 27 (46.6%) patients; a renal
assessment in 9 (15.5%) patients; an ionogram in 3 (5.2%)
patients.
3.6.1. Early Complications
The postoperative course was complicated in 24 (41.4%)
patients with 5 (8.6%) deaths.
3.6.2. Types of Postoperative Complications and Traitement
The seven (12.1%) patients who developed anemia
received a packed red blood cell transfusion.
The 9 (15.5%) patients with parietal suppuration received
daily dressing.
For the two (3.2%) postoperative peritonitis and the
digestive fistula associated with the evisceration, a repeat
Percentage operation was performed under general anesthesia.
43.1 The patient in respiratory distress was oxygenated (6l/min),
19 with a combination of furosemide (80mg) and Betametasone
17.2 4mg.
3.6.3. Causes of Death
Two patients died of septic shock associated with anemia.
Other causes of death were hypotension plus respiratory
100 distress, altered consciousness, parietal suppuration plus
digestive fistula and evisceration were found in one patient
each.
3.6.4. Morbidity and Mortality
The perioperative morbidity rate was 41.4%.
The perioperative mortality rate was 8.6%.
3.6.5. Length of Stay in the Intensive Care Unit
The average length of stay in the intensive care unit was
8.7 days, with extremes of 4 and 64 days.
4. Discussion
4.1. Epidemiological Aspects
4.1.1. Frequency of Peritonitis
Peritonitis was the first cause of abdominal surgical
emergencies at CHU-Kara with a percentage of 27.8%. This
can be explained by the precarious hygiene conditions in our
environment, self-medication, delay in consultation at the
CHU-Kara and the high frequency of infectious pathologies
in surgery. Traoré, Ouangré and Dissa [5-7] made the same
observation with 34.9%, 31.2% and 21.14% respectively.
This frequency could be linked to the high frequency of
infectious diseases (typhoid fever, peptic ulcer) resulting
from poor food hygiene and lack of vaccination on the one
hand, and a delay in consultation, diagnosis and upstream
management of the main diseases involved on the other.
A respect of elementary rules of hygiene and an early
consultation would make it possible to considerably reduce
this frequency.
4.1.2. Sex
The male sex was the most represented, with a sex ratio of
1.8. This result can be explained by the risk factors to which
men are more exposed (smoking, alcohol, non-steroidal anti-
inflammatory drugs). The same male predominance was
 International Journal of Anesthesia and Clinical Medicine 2023; 11(1): 5-13
noted in the studies of Harouna [2], Traoré [5], Dissa [7] and
Yacouba [8] with sex ratios of 1.96, 2.1, 2.70 and 3.2
respectively.
4.1.3. Age
The mean age was 29.6 years. This juvenile predominance
is characteristic of developing countries. It was similar to
those of Dissa [7], Ouangré [6] and Ramachandran [9] with
respectively 24, 24.3 and 32 years. However, this age was
lower than the 48 years of Cougard [10] in France in 2000.
This disparity is linked to the ageing of the population in
France and to the high frequency of pathologies such as
complications of appendicitis, perforated gastro-duodenal ulcer
and typhoid fever in young subjects in Africa and Asia [7].
4.1.4. Main Activities of the Patients
The majority of patients were farmers (22.4%), followed
by schoolchildren (17.2%). This predominance of peasants is
linked to their low socio-economic level, the lack of respect
for hygiene measures and the absence of health coverage, all
of which contribute to delays in consultation and treatment.
The same observation was made by Yacouba [8] and
Ouangré [6] with 35.7% and 38.5% respectively. While
Makita, Traoré and Dissa [11, 5, 7] had a predominance of
schoolchildren and farmers in second place. The extension of
health insurance to this socio-professional class would reduce
the frequency of this disease or its complications.
4.1.5. Origin
The residence and/or origin of the patients was 87.9% in
the Kara region. This would be related to the fact that most of
the regions of Togo were equipped with a surgical technical
platform and qualified personnel capable of effectively
managing peritonitis. Few (10.1%) peritonitis cases were
referred from other health regions.
4.1.6. Hour to Admission
The average time to consultation for patients was 84 hours
(3.5 days). The usual delay in consultation was attributable to
cultural and especially economic factors. The lack of
knowledge of the seriousness of the disease, self-medication,
non-adapted treatments, and the absence of social security
coverage in case of illness for the majority of the population
were other factors contributing to this delay.
Delayed consultation and insufficient financial resources
were the main causes of high morbidity and mortality in
health facilities according to Traoré, Dissa and Dembélé [5, 7,
12].
4.1.7. Mode of Admission
The majority of patients received in the emergency room
(67.2%) were referred from a peripheral health center to Kara
University Hospital. This high rate of referral really testifies
to the fact that Kara University Hospital was the reference
center because of its technical facilities and qualified
personnel for the management of this disease.
This high rate in our context can be explained by the fact
that the majority of patients came from peripheral health
facilities without surgical branches.
9
4.1.8. Treatment Received Before Admission
Analgesics (41.4%) and antimalarials (31%) were the main
treatments received by patients before admission. This
treatment could be explained by the fact that the main
symptoms of the disease were fever, pain and asthenia. An
additional factor would be the insufficient qualification of the
peripheral staff in relation to this pathology.
4.2. Diagnostic Aspects
4.2.1. Clinical Status (Table 1)
Fever, usually high at the onset of symptoms (except in
gastric perforations), was the most frequent general sign in
our context (72.4% of cases). It is a sign of bacterial
contamination. This was similar to the data of Dissa [7] and
Yacouba [8] with respectively 81% and 93% of cases.
4.2.2. Para Clinical Evaluation (Table 2)
All patients (100%) had undergone a minimal preoperative
workup including Rhesus grouping, uremia, blood glucose,
creatinine and a CBC. In emergency, only the white blood
cell count and the hemoglobin level were performed.
For etiology, paraclinical examinations were performed:
ASP and abdominal ultrasound respectively 91.4% and 27.6%.
This disparity observed between the two examinations would
be related to the fact that the ASP was the only imaging
examination always available in emergency. Dembélé [12],
Cougard [10] in France had similar results for the ASP with
respectively 88% and 86.8%. For ultrasound Sakhri [13] and
Dissa [7] found higher rates than ours with 75% and 88%.
These results confirm the lack of radiologists at the CHU-
Kara on call to perform an emergency ultrasound.
No CT scan was performed because of its non-existence at
CHU-Kara, nor in the northern region of the country.
4.2.3. Etiological Aspects (Table 3)
Acute generalized peritonitis due to peptic ulcer
perforation was the most common cause of infection (43.1%),
followed by ileal perforation of typhoid origin (24.1%) and
appendicular peritonitis (17.2%). The high predominance of
peptic ulcer perforations could be explained by the lack of
knowledge of the population of peptic ulcer and its
complications, self-medication with the abusive use of non-
steroidal anti-inflammatory drugs.
This predominance of peptic ulcer perforations was also
reported in the study by Sarah El A [14]. On the other hand,
Ouangré [6] found, in decreasing order of frequency, typhoid
perforations of the small intestine, followed by appendicular
peritonitis and peptic ulcer perforation.
The high frequency of infectious origins found in the
African series testifies to the precarious food hygiene
conditions in African populations.
4.3. Therapeutical Aspects
4.3.1. Preoperative Period
(i). Preoperative Resuscitation
In our context, all patients had undergone preoperative
10 Essohanam Tabana Mouzou et al.: Anesthesiological Management of Acute Generalized Peritonitis at Chu Kara
resuscitation. Crystalloids were used for filling and energy
supply.
Two patients were transfused with packed red blood cells.
Oxygen was administered to eleven (19%) patients.
(ii). Antibiotic Therapy
The combination of Ceftriaxone 100mg/kg/day and
Metronidazole 30mg/kg/day was administered in 51 (87.9%)
patients, tripled with Gentamycin 5mg/kg/day in 4 (6.9%)
patients. The adoption of this antibiotic therapy was due to its
efficacy on aerobic and anaerobic germs in generalized
peritonitis and to its good intraperitoneal penetration. These
same associations were used in the studies by Ouangré [6],
Dissa [7] and Yacouba [8].
(iii). Average Duration of Preoperative Resuscitation
It was 17h 18 minutes. This result can be explained by the
arrangements made by the different anesthetic and surgical
teams for the rapid management of surgical emergencies.
This delay was lower than the 24 and 25 hours found
respectively in the studies of Makita-Ngadi [11] and Sarah
[14] but similar to the 16 hours of Dissa [7].
Atypical presentations (frustrated forms and asthenic
forms), financial problems, delay in referral, and poor
clinical condition of patients on admission were factors that
increased the duration of resuscitation.
Continuous training of front-line staff in peripheral health
facilities would help reduce the duration of preoperative
resuscitation.
4.3.2. Perioperative Period
(i). General Anesthesia
General anesthesia plus orotracheal intubation was used in
93.1% of cases.
Premedication was done mainly with Diazepam, Atropine
and Fentanyl. These drugs were used alone or in combination.
The combination (Diazepam + Atropine + Fentanyl) was
administered in 21 (36.2%) patients, followed by the
combination (Atropine + Fentanyl) in 32.8%. The
premedication performed in our study corresponded well to
the standard measures.
Preoxygenation was performed in all patients who
received general anesthesia, a practice that is appropriate for
all general anesthesia. It was also systematic in the study
carried out by Ongoungou [15] and that of Gaye [16].
a. Induction
Pancuronium was the most used drug for induction of
anesthesia in 67.2% of patients, followed by Propofol in 53.4%
and Fentanyl in 51.7%. Pancuronium was the most used
curare due to its availability and affordability in our setting.
Rapid sequence induction was not used at any time. This
would be due to the increasing trend to abandon it.
b. Maintenance
Maintenance of general anaesthesia was achieved by
administration of Fentanyl in 39 (67.2%) patients, followed
by Propofol in 32 (55.2%) and Forene in 10 (17.2%) patients.
In a study carried out by Timbo [17] the anesthesia was
maintained with Fluothane (100%). There are no
contraindications to the use of an anesthetic agent, and all
can be used. The choice is based more on the patient's
comorbidities (cardiac or renal insufficiency).
(ii). Spinal Anesthesia
a. Premedication
One of the four patients who underwent spinal anesthesia
was premedicated with Atropine and Diazepam.
b. Spinal Anesthesia Protocol
Bupivacaine alone was administered in two (3.5%)
patients as well as the combination of Bupivacaine +
Morphine. Bupivacaine is the real local anesthetic while
morphine is only an adjuvant. The use of spinal anesthesia in
cases of acute generalized peritonitis is a bad practice and
should be banned.
(iii). Average Duration of Anesthesia
It was 105 minutes with extremes of one hour and 3 hours
45 minutes. It was a function of the duration of the surgery.
This duration can be explained by the short duration of the
surgical procedures. Ongoungou [15] and Gaye [16] had
found average durations higher than ours with respectively
158 minutes and 147 minutes. This short duration of
anaesthesia compared to the two previous ones would be
related to the competence and the surgical speed.
(iv). Intraoperative Complications
No intraoperative complications were found. This was due
to the fact that these complications were not reported on the
anesthesia charts. This bad practice is the responsibility of
the paramedics who omitted to notify them after anesthesia
and interventions.
(v). Interventions Performed (Table 4)
Peritoneal cleansing and drainage were performed in all
patients, followed by excision-suture of the stomach which
was the most performed surgical procedure with 43.1%,
followed by excision-suture of the small intestine 19%. This
was related to the fact that peritonitis due to peptic ulcer
perforation was in the majority in our context. This treatment
is similar to that of Dembélé [12] and Sarah [14] in whom
suture of the stomach was also the first line of treatment with
respectively 45% and 51.4%. The therapeutic attitude to
acute peritonitis depends on the surgeon's intraoperative
assessment. Excision-suture of the stomach would be
particularly effective for perforations of peptic ulcers.
4.3.3. Post-Operative Care
(i). Fluid and Energy Intake
Postoperative fluid and electrolyte intake consisted of 0.9%
saline in combination with Nacl and Kcl in all patients (100%),
lactated Ringer's in 17.2% of cases. For energy intake, 10%
glucose was administered in 54 (93.1%) patients. These
intakes were well adapted to the classical regimens.
Postoperative pain management was ensured with
analgesics (level I, level II, level III) and NSAIDs.
Paracetamol + Nefopam was the most commonly used
 International Journal of Anesthesia and Clinical Medicine 2023; 11(1): 5-13
combination in 39 (67.2%) patients, followed by Paracetamol
+ NSAID (15.5%). Postoperative analgesia was analgesia
was provided by Paracetamol, Nefopam and/or Tramadol in
the series of Gaye [16]. In Touré, on the other hand,
Morphine was used with or without Paracetamol for patients
hospitalized in the ICU. Postoperative analgesia was
multimodal.
(ii). Antiulcer Treatment
Treatment of peptic ulcer (peptic perforation) was
performed as well as prevention of stress ulcer in 27 (46.6%)
patients. Antiulcer treatment was performed in all patients in
the studies conducted by Cougard [10] and Kafih [18].
Antiulcer treatment is systematic in the management of
peptic ulcer perforation peritonitis.
(iii). Surveillance
It was clinical and paraclinical. Postoperative clinical
monitoring was based on temperature, blood pressure, heart
rate, respiratory rate, oxygen saturation, diuresis, nasogastric
tube, drain, status of the surgical wound, resumption of
transit, lungs and heart. This monitoring was performed in all
patients.
The paraclinics were based on the clinical signs of appeal.
It was mainly made of blood count, renal assessment and
blood ionogram.
(iv). Anticoagulant Treatment
The prevention of venous thromboembolic complications
was ensured by low molecular weight heparins in two (3.4%)
patients with risk factors. Gaye [16] in 2016 had found
27.9%.
(v). Antibiotic Therapy
Postoperative antibiotic therapy was identical to that
administered preoperatively. It was modified in only 13
(22.4%) patients by adding Gentamycin to the initial regimen.
There was no culture of peritoneal fluid. This same
observation was made by most African authors such as de
Ngatcha [19], Cissé [20] and Harouna [2]. Antibiotic therapy
combining Ceftriaxone, Metronidazole and Gentamycin was
used in these African series according to its efficacy on the
aerobic and anaerobic bacteria frequently encountered in
these environments.
The insufficiency of the technical platform had made it
impossible to culture the peritoneal fluid for the isolation of
germs and the establishment of an antibiogram.
4.4. Evolution
4.4.1. Postoperative Complications
(i). Parietal Suppuration
This was the most frequent complication with a rate of
15.5%. The low frequency of parietal suppuration in our
context could be explained by the aseptic conditions
observed intraoperatively and during postoperative care and
the systematic antibiotic therapy. This finding was similar to
most African series, such as those of Harouna, Traoré and
11
Dembélé [2, 5, 12] with rates varying from 18% to 23%.
Early consultation and management under better aseptic
conditions would contribute to further reduce the frequency
of parietal suppuration.
(ii). Postoperative Peritonitis
It represented 3.4% of cases. Postoperative peritonitis
was related to suture release and uterine perforation. This
rate was similar to that of Sambo [21] and Ouangré [6] who
found 3.8% and 4.1% respectively. They are rare but
dreadful because of their poor prognosis with a mortality
rate of around 70% [22], hence the need for good
postoperative monitoring for diagnosis and early
management.
(iii). Respiratory Distress
In one of the patients, multivisceral failure was related to
sepsis.
4.4.2. Treatment of Postoperative Complications
The seven (12.1%) patients who developed anemia each
received adult bags of packed red blood cells.
The 9 (15.5%) patients with parietal suppuration received
a daily dressing.
The two (3.2%) postoperative peritonitis and the digestive
fistula associated with the evisceration were reoperated in the
OR under general anesthesia. The evolution after recovery
was favorable for the two cases of postoperative peritonitis,
but the fistula led to death.
The patient in respiratory distress had benefited from the
administration of oxygen, diuretic and corticoid with an
unfavorable outcome marked by death.
4.4.3. Morbidity and Mortality
(i). Morbidity
The postoperative course was complicated in 24 (41.4%)
patients. This high morbidity was associated with the high
morbidity of acute generalized peritonitis of typhoid origin
and gastroduodenal ulcer perforation, and the hypovolemic
and septic shock states associated with these conditions.
These data were comparable to the 46% and 40.2% of
Harouna [2] and Ouangré [6]. Lower morbidities were
reported by Dembélé [12] and Dissa [7] 13.5% and 21%. The
management of patients at an advanced stage of the disease,
associated with insufficient financial resources of the parents,
were the main factors favoring the disease.
(ii). Mortality
Perioperative mortality was 8.6%. It was related to the
delay in consultation and management, the lack of qualified
personnel and the insufficient financial resources of the
parents. The mortality rate was not different from those of
Kassegné [23] in Kara and Traoré [5] in Mali. It was higher
than 1% in Cougard [10] in France. The factors associated
with death were septic shock, hypovolemic shock and
polyvisceral failure reported by other authors such as
Harouna and Yacouba [2, 8]. Laparotomy surgery practiced
in most of our African contexts should be progressively
12 Essohanam Tabana Mouzou et al.: Anesthesiological Management of Acute Generalized Peritonitis at Chu Kara
replaced by laparoscopic surgery because of its low
morbidity and mortality rate [7].
(iii). Length of Stay in Intensive Care
The average length of stay in the intensive care unit was
8.7 days with extremes of 4 days and 64 days. This duration
was influenced by postoperative complications such as
parietal suppuration, digestive fistula, evisceration,
postoperative peritonitis and sepsis. It varied according to the
etiologies. It was 6.8 days for appendicular peritonitis; 14.8
days for gynecological peritonitis; 7.4 days for peptic ulcer
perforation; 9.5 days for diverticular perforation; and 9.2
days for typhoid perforation. This means that the etiology has
a significant impact on the duration of postoperative
resuscitation. The higher the degree of sepsis of the
peritonitis, the longer the postoperative resuscitation.
Because of their severity, peritonitis should not suffer from a
delay in management, which contributes to reducing the
length of hospitalization. This was similar to that of Dissa [7]
and Mabewa [24] who found 9 days and 7 days respectively.
On the other hand, Adesunkanmi [25] and Mehinto [26]
found higher figures of 11.6 days and 12 days respectively.
5. Conclusion
The anesthesiological management of acute generalized
peritonitis at CHU-Kara from November 1, 2019 to October
31, 2020 revealed:
1) The hospital frequency of acute generalized peritonitis
of 27.8% in relation to operated surgical emergencies.
It was the first cause of surgical emergencies in
digestive surgery.
2) Young subjects were more affected, with a male
predominance.
3) Peptic ulcer perforation was the main etiology,
followed by typhoid perforation.
4) Preoperative resuscitation was performed in all
patients and contributed to correct the
hydroelectrolytic and energetic disorders, to a
probabilistic antibiotic therapy combining Ceftriaxone
and Metronidazole.
5) Anesthesia for surgery was associated with general
anesthesia plus orotracheal intubation, which was the
most common, followed by spinal anesthesia.
6) Preoxygenation was performed in all patients who
received general anesthesia.
7) Premedication was combined with Diazepam, Atropine
and/or Fentanyl.
8) Pancuronium was the most commonly used curare for
induction of general anesthesia.
9) Bupivacaine was the only local anesthetic used for
spinal anesthesia.
10) Excision-suture of the stomach was the most common
operative technique followed by excision-suture of the
small intestine.
11) The postoperative care had associated multimodal
analgesia, continuation of antibiotic therapy,
administration of antiulcer drugs, vascular filling and
energy supply.
12) Postoperative morbidity was 41.4%, dominated by
parietal suppurations. Mortality was 8.6%.
13) The main factors of poor prognosis were delayed
referral and insufficient financial resources of the
parents.
References
[1] Calin Lazar Constantin. Memory boarding school,
Vernazobres - Gregor editions, 99 bd de l'Hôpital -75013.
Paris 2006: Surgical emergencies, 2nd Edition: n° 275;
peritonitis P109.
[2] Harouna YD, Abdou I., Saibou B, and Bazira L. Peritonitis in
the tropics: etiological particularities and current prognostic
factors: about 160 cases. Méd Afr Noire 2001; 48 (3): 103 -
106.
[3] Adamson K, Gamdy GN, James LS. The influence of thermal
factors upon oxygen consumption of the newborn infant. J
Pediatr 1965; 66: 495-503.
[4] Coulibaly CO. Acute generalized peritonitis in the general
surgery department of the hospital of Sikasso about 101 cases.
Thesis med Sikasso 2010 M408: P60.
[5] Traoré LS. Studies of acute peritonitis at the CHU of Kati.
These. Thesis med Bamako 2014.
[6] Ouangré E. Les péritonites aiguës généralisées en milieu rural
au Burkina Faso: A propos de 221 cas, Revue Africaine et
Malgache de Recherche Scientifique/Sciences de la Santé, vol.
1, no. 2, Art. No. 2, Apr. 2014.
[7] Dissa B. Les péritonites aiguës aspects cliniques,
diagnostiques et thérapeutiques à l'hôpital Fousseyni Daou de
Kayes. Thesis med, Bamako 2012; n°53.
[8] Yacouba A. Acute peritonitis in the regional hospital of GAO.
Thesis med, Bamako 2011; N°35.
[9] Ramachandran CS, Agarwal S. Laparoscopic Surgical
management of perforative peritonitis in enteric fever: a
preliminary Study. Surg New Delhi 2004; 14 (3): 122-4.
[10] Cougard P, Barrat C. Laparoscopic treatment of duodenal
ulcer perforations. Results of the SFCL multicenter survey.
Ann. Chir. 2000, 125: 726 - 731.
[11] Aghazadi TR, Almou, Boukind B. Anterior seromyotomy and
posterior vagotomy in the treatment of perforated ulcer. Ann
Chir 1992; 124 (5): 2 - 299.
[12] Dembélé B. M. Study of acute generalized peritonitis in the
general and pediatric surgery departments of Gabriel Touré
Hospital. Medical thesis, Bamako 2005; N°215.
http://indexmedicus.afro.who.int/iah/fulltext/Thesis_Bamako/
05M215.pdf.
[13] Sakhri J. Treatment of perforated duodenal ulcers. Tunisie
Médicale 2000; 78 (8): 9.
[14] Sarah El A. Acute generalized peritonitis treated in the
visceral surgical emergency department at IBN Sina hospital
in Rabat (About 210 cases). Thesis Morocco medicine 2020.
 International Journal of Anesthesia and Clinical Medicine 2023; 11(1): 5-13
[15] Ongoungou N and Amonkou A. Anesthesiological
management of community peritonitis: limitations and
difficulties in 30 cases collected at the University Hospital of
Yopougon. Thesis UFR des Sciences Médicales Abidjan 2007.
[16] Gaye I, Leye PA, Traoré M, Ndiaye PI, Ba B, Diouf E.
Perioperative management of abdominal surgical emergencies
in adults at CHU Aristide le Dantec. Afr Med 2016; 24: 190.
[17] Timbo A. Laparoscopic cholecystectomy in sickle cell
patients: evaluation of anesthesiology management at CHU
point G [Thesis]. Medicine and Odostomatology: Mali; 2014.
119.
[18] Kafih M, Fekak H, El Idrissi A, Zerouali O. Perforated
duodenal ulcer: laparoscopic treatment of perforation and
ulcer disease. Ann chir 2000; 125: 242-6.
[19] Mbiandoun Ngatcha GS. Postoperative complications in the
intensive care setting: epidemiological and clinical profile.
Thesis of medicine Bamako 2013.
[20] Cissé I. Digestive perforations in the general and pediatric
surgery department of Gabriel TOURE hospital. Med thesis,
Bamako 2003, M 54.
[21] Sambo B, Allodé S. Prise En Charge Des Péritonites Aiguës
Dans Un Hôpital De District En Afrique Sub-saharienne: Cas
13
Du Bénin, European Scientific Journal, ESJ, vol. 13, no. 36,
Art. No. 36, Dec. 2017.
[22] Gilles B. Nosocomial infections: epidemiology, diagnostic
criteria, prevention, principles of treatment. Revue du
praticien 1997; 47: 201-09.
[23] Kasségné I, Kanassoua KK, Sewa EV, Sambiani DM, Ayité
AE. Management of acute generalized peritonitis at the
University Hospital of Kara. Saranf 2013; 18 (2): 115-21.
[24] Mabewa A, Seni J, Chalya PL, Mshana SE, Gilyoma JM.
(2015). Etiologies, treatment outcome and factors among
patients with secondary peritonitis at Bugando Medical Centre,
Mwanza, Tanzania, World J Emerg Surg 2015; 10: 47.
[25] Adesunkanmi AR, Oseni SA, Adejuyigbe O, Agbakwuru EA.
Acute Generalized Peritonitis in African Children:
Assessment of severity of illness using modified APACHE II
Score. ANZ J surg Nigeria 2003; 73 (5): 275 - 9.
[26] Mehinto DK, Gandaho I, Adoukonou O, Bagnan OK,
Padonou NA. Epidemiological, diagnostic and therapeutic
aspects of small bowel perforations of typhoid origin in
visceral surgery at the Centre National Hospitalier et
Universitaire-Hubert Koutoucou Maga de cotonou. Méd Afr
Noire 2010; 57 (11): 535-40.